Fillable FORM LC ATC03 Medica Certificate Validation2019 (Bermuda Civil Aviation Authority)

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FORM LC ATC03 Medica Certificate Validation2019 (Bermuda Civil Aviation Authority)

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IV. CERTIFICATION:
APPLICATION FOR MEDICAL CERTIFICATE OF VALIDATION FOR AIR TRAFFIC CONTROLLERS
I. APPLICATION INFORMATION MEDICAL CERTIFICATE INITIAL RENEWAL
A. Full Name (First, Middle, Last)
B. Date of Birth
C. Place of Birth
D. Nationality
(dd-mm-yy)
E. SEX
F. HEIGHT
G. Weight
H. Hair colour
I. Eye colour
Male Female
(Inches)
(Lbs)
J. Address & Contact numbers:
Telephone: Facsimile: E-mail:
A. Issuing Authority:
B. Class of Certificate:
a. Current Medical Certificate (FAA Class II) - original or certified true copy in electronic format.
b. Documentary evidence from the issuing State verifying the validity of the submitted medical certificate (for first time
applicants only).
Verification for FAA Class II may be accomplished by calling the FAA Medical Centre office and requesting
the information to be provided to the Bermuda Civil Aviation Authority.
Alternatively, a copy of the medical certificate issued should be sent directly to the Bermuda Civil Aviation Authority
by the approved FAA medical examiner.
I certify that the above information is true and correct to the best of my knowledge.
It is an offence to make, with the intent to deceive, any false representation for the purpose of procuring the grant, issue,
renewal, or variation of a licence. Any person so doing renders himself liable, on summary conviction, to a fine not exceeding
£1000 (or equivalent) or on conviction on indictment to a fine or imprisonment for term not exceeding two years or both.
Signature of Applicant _____________________
Date: _______________________
(dd-mm-yy)
PEL/Form ATC 03 (2018/12)
II. MEDICAL CERTIFICATE INFORMATION:
C. Date of Issue:
D. Expiration Date:
D. Medical Limitations:
III. THE FOLLOWING DOCUMENTS MUST BE ENCLOSED WITH THIS APPLICATON:
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FORM LC ATC03 Medica Certificate Validation2019 (Bermuda Civil Aviation Authority)

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Completed 22 July 2021

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